NAM is the official provider of online scientific reporting for the
8th International AIDS Society Conference on HIV Pathogenesis, Treatment
and Prevention (IAS 2015), which will take place in Vancouver, Canada,
19th-22nd July 2015.

When you and your doctor
discuss starting HIV treatment, a range of factors will be taken into account
in deciding the best anti-HIV drugs for you. These will include your health and
your lifestyle. An additional factor now is cost. HIV treatment is very cost-effective
but is also costly. The way HIV treatment is prescribed in London changed in April
2011 in order to make savings; reducing the drugs budget will protect services
from being cut. This factsheet sets out the changed prescribing guidelines for
people starting treatment (‘first-line treatment’), and explains some of the
issues to consider.

Who will the prescribing changes affect?

The new prescribing guidelines will apply to people starting
treatment for the first time and to people who need to change from their current
treatment to a protease inhibitor (PI)-based regimen.

Previously, people were likely to start treatment on a
combination of efavirenz and the drugs tenofovir and FTC (emtricitabine) combined as Truvada; these three drugs are also
in a single pill Atripla, which people could change to once stable on treatment. The new guidance means people on
first-line treatment will still take two pills a day rather than one, but taken
together, once a day.

Where Kivexa is
not appropriate, Truvada is the recommended alternative. Truvada could be prescribed if you:

are
shown to be at risk of hypersensitivity reaction to abacavir on a pre-treatment
test.

If efavirenz is not suitable, the next option
would be nevirapine (Viramune),
another NNRTI, or treatment with a PI rather than
an NNRTI. Patients starting with a PI will start with the drug atazanavir
(Reyataz), ‘boosted’ with another PI,
ritonavir (Norvir). Darunavir
(Prezista) is recommended
as the alternative PI for patients who have resistance to atazanavir or cannot
tolerate it. The latter group might include people on a group of drugs called
PPIs (used to treat acid reflux and ulcers) because of the risk of interaction,
and people with a history of kidney stones.

The integrase inhibitor raltegravir (Isentress) will only be used in very specific circumstances:
short-term use in first-line treatment for patients with very
complex drug interactions, or for pregnant women diagnosed with HIV
late in pregnancy, where there is a need for very rapid viral load reduction.
As soon as the clinical need has passed, the patient will be switched to
another, less expensive drug, which is not expected to affect the outcomes of their treatment.

How were the new first-line drugs chosen?

The clinical outcomes of a number of drugs are now broadly similar.
The London HIV Consortium (see below) has decided that cost can be taken into
account without compromising quality of care. The new guidelines were produced
by the LHC in consultation with lead London
clinicians.

The changes were in line with the British HIV Association
(BHIVA) treatment
guidelines current at the time. New treatment guidelines were published in August 2012; these list abacavir/ 3TC (Kivexa) as acceptable alternative NRTIs for people starting HIV treatment.

The LHC plans to audit the clinical effect, if any, of
these changes in prescribing practice in order to determine what effect they
have on patient outcomes.

Does this mean that some drugs will no longer be available?

No. If there are reasons to use different treatments, all
the currently available anti-HIV drugs are still an option. Reasons could be:

the
side-effects of a particular drug and their impact on a
patient’s health and day-to-day quality of life

having another condition or interactions with any other
medications a patient is taking.

The LHC has undertaken that: “HIV doctors will
continue to ensure treatment is tailored to the needs of the individual patient
and, where it is clinically appropriate to do so, will use the least expensive
treatment option available. If the least expensive drugs are not clinically
appropriate for a patient, then HIV doctors will select a different treatment
that will keep the patient well and reduce their viral load to undetectable
levels.”

What are the side-effects of the drugs in the new guidelines?

There are some concerns around the potential side-effects of
abacavir, contained in Kivexa. Studies
have come up with contradictory findings as to whether it increases the risk of
heart attack. Because of this concern, Truvada, instead of Kivexa, will be prescribed to patients
with a high heart attack risk score.

Atazanavir does not raise blood lipids (fats) as much as
other PIs and is taken as one capsule, once a day, so for some
people it will mean a reduction in the number of pills. It has been linked to kidney stones in a few patients
and can cause a harmless but sometimes marked form of jaundice.

Why have these changes been made?

The changes in prescribing are due to a new two-year drug
purchasing agreement made between the LHC and the drug companies.

The LHC represents the majority of London’s hospital and primary care trusts (PCTs)
and has considerable negotiating power. It has
managed over the years to pay about 25% below list price for antiretrovirals.

The prescribing changes were determined by the LHC after PCTs
in London told
HIV prescribers that their budget would not grow this year. Hospitals need to
save £9 million on drugs in order to accommodate other HIV patient and clinic
costs: 19% of the entire 2009 London NHS
drugs budget was spent on anti-HIV drugs.

It was initially thought that clinics that did not
abide by the new prescribing guidelines could be sanctioned by having their
drugs budget cut or withheld, but it has now been confirmed that this is not
the case.

This content was checked for accuracy at the time it was written. It may have been superseded by more recent developments. NAM recommends checking whether this is the most current information when making decisions that may affect your health.

NAM’s information is intended to support, rather than replace, consultation with a healthcare professional. Talk to your doctor or another member of your healthcare team for advice tailored to your situation.